Dec. 17, 2024 [April 6, 2025]
We’re changing prior authorization requirements that may apply to some commercial members to reflect new, replaced or removed codes. These changes are based on updates from Utilization Management prior authorization assessment, Current Procedural Terminology (CPT®) code changes released by the American Medical Association or Healthcare Common Procedure Coding System changes from the Centers for Medicaid & Medicare Services. A summary of changes is included below.
Note: these changes are updates to Prior Authorization requirements for Administrative Services Only accounts and for optional Recommended Clinical Review for Fully Insured members.
Important Reminder: Always check eligibility and benefits first through Availity® Essentials or your preferred vendor portal, prior to rendering services. This step will confirm prior authorization requirements and utilization management vendors, if applicable.
Changes include:
- April 1, 2025 – Addition of Genetic Testing codes to be reviewed by Carelon
- April 1, 2025 – Removal of Genetic Testing codes previously reviewed by Carelon
- April 1, 2025 – Addition of Medical Oncology drug codes to be reviewed by Carelon
- April 1, 2025 – Addition of a Musculoskeletal code to be reviewed by Carelon
- April 1, 2025 – Removal of a Medical Oncology code previously reviewed by Carelon
- April 1, 2025 – Removal of a ISoC Specialty Pharmacy code previously reviewed by BCBSNM
- April 1, 2025 – Addition of a ISoC Specialty Pharmacy code to be reviewed by BCBSNM
- April 1, 2025 – Removal of a Specialty Pharmacy code previously reviewed by BCBSNM
- April 1, 2025 – Addition of Specialty Pharmacy codes to be reviewed by BCBSNM
More Information: Refer to the updated prior authorization CPT Code Lists section on the Preservice Reviews page. The code changes will be designated with dates of removal or addition.
Avoid post-service medical necessity reviews and delays in claim processing by obtaining prior authorization before rendering services. If prior authorization is required, services performed without prior authorization or that do not meet medical necessity criteria may be denied for payment and the rendering provider may not seek reimbursement from the member.
CPT copyright 2023 American Medical Association. All rights reserved. CPT is a registered trademark of the AMA.
Carelon Medical Benefits Management is an independent company that has contracted with Blue Cross and Blue Shield of New Mexico to provide utilization management services for members with coverage through BCBSNM. Availity is a trademark of Availity, LLC, a separate company that operates a health information network to provide electronic information exchange services to medical professionals. Availity provides administrative services to BCBSNM. BCBSNM makes no endorsement, representations or warranties regarding any products or services provided by third party vendors.